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Lot survey <br />Other requirements; ~ // ~ <br /> <br />To Be Completed by ~nst~Her <br /> ~P No ~.- <br />Total n~ber: L;ving unHs ..... <br /> Water aupply: Public lySlem~lndlvidual well ~ ~ .Com~unlty ~yste~. , <br /> Septic tanb Ofslance from well ~ ~ , ~eet. Material ~ ' ',~No. of comportme~l,~ <br />Total I~quld capacity J~ ~.~ ( gal,[nslde length ,, ~ff, inside width~ <br /> D omelet ... ,ft. L~ depth <br />Tile disposal fle~d: Distri~tio~b~? Yes ~ ~o ~ ~fhe~ ........ <br />Length o~ each ne~,,~ ~' ........ <br /> <br />Wldlh ~ ~rench ~ ~ ~ ' ' ._ fl. Well~ .~ft. <br />Total square ~oo~ge_~ .... fl., Nearest <br />D~s/once between llnes~ ft. Lot line; Dto~t ~ Side~ Rear ~ fl .... <br /> Foundation,. fl. <br />Type of filter malertoh Gravel: ~. ~ ..... Other~Depth beneath Hie ,,, ~ ~ I I~cfles, <br /> <br /> of installation, ~ <br /> <br />"DATE! <br /> <br /> Syslem apparently will [~'e'~'~'ill not [] <br /> <br />Indicate Northerly direction, <br />Inlpeetlon wlll hal be mode until completed form ia returned to the Health. Dept. <br /> <br /> Signature, of Inl~ller~ <br /> ~Fcm H&a,c"rH OE~, us~} ~ ~ <br /> function satisfactorily, and is therefore approved ~isopprovgd ~ <br /> <br />Cap,es'- (11 Orlg. HO Files <br /> <br /> <br />